Nokea
The home health nurse is visiting a client with HIV who is 6 weeks postdelivery. Which of the following findings would indicate that patient teaching by the nurse in the hospital was successful?
- A. The client is breastfeeding her baby every two hours.
- B. The client is using a diaphragm for family planning.
- C. The client is taking her temperature every morning.
- D. The client is seeking care for a recent weight loss.
Correct Answer: D
Rationale: Weight loss may indicate opportunistic infection.
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A postpartum patient asks, “Will these stretch marks ever go away?” Which is the nurse’s best response?
- A. “No, never.”
- B. “Yes, eventually.”
- C. “They will fade to silvery lines but won’t disappear completely.”
- D. “They will continue to fade and should be gone by your 6-week checkup.”
Correct Answer: C
Rationale: The correct answer is C: “They will fade to silvery lines but won’t disappear completely.” This response is the best because it provides a realistic expectation to the patient. Stretch marks may lighten over time but typically do not completely disappear. Choice A is incorrect as it provides a definitive and discouraging answer. Choice B is vague and does not offer a clear timeframe. Choice D is incorrect as it gives an overly optimistic timeline that may not be realistic for most individuals. Overall, choice C is the most accurate and supportive response for the patient's query.
The nurse has administered Benadryl (diphenhydramine) to a post-cesarean client who is experiencing side effects from the parenteral morphine sulfate that was administered 30 minutes earlier. Which of the following actions should the nurse perform following the administration of the drug?
- A. Monitor the urinary output hourly.
- B. Supervise while the woman holds her newborn.
- C. Position the woman slightly elevated on her left side.
- D. Ask any visitors to leave the room.
Correct Answer: B
Rationale: Supervision ensures safety due to potential sedation.
A home care nurse is visiting a breastfeeding client who is 2 weeks postdelivery of a 7-lb baby girl over a midline episiotomy. Which of the following findings should take priority?
- A. Lochia is serosa.
- B. Client cries throughout the visit.
- C. Nipples are cracked.
- D. Client yells at the baby for crying.
Correct Answer: D
Rationale: Yelling at the baby raises concerns about bonding.
Which symptom would the nurse expect to observe in a postpartum client with a vaginal hematoma?
- A. Pain.
- B. Bleeding.
- C. Warmth.
- D. Redness.
Correct Answer: A
Rationale: Pain is a common symptom of a vaginal hematoma.
The postpartum nurse is reviewing dietary practices for an Asian patient. Which of the following should the nurse expect to observe as a dietary practice for this culture?
- A. Special foods brought from hom
- B. Preference for fresh fruits.
- C. Preference for “cold” foods.
- D. Request for ice water instead of hot water.
Correct Answer: A
Rationale: The correct answer is A: Special foods brought from home. Asian cultures often have specific dietary practices and beliefs related to postpartum care. Bringing special foods from home is a common practice to support recovery and promote health. This may include traditional dishes thought to have healing properties.
B: Preference for fresh fruits is not specific to Asian cultures and may not necessarily be a common dietary practice postpartum.
C: Preference for “cold” foods is not a general characteristic of Asian dietary practices and may not be specifically related to postpartum care.
D: Request for ice water instead of hot water is not a general dietary practice in Asian cultures and is not directly related to postpartum care.